Genomic Profiling of Patients With Advanced Biliary Tract Cancer May Reveal Treatment Opportunities

The incidence of biliary tract cancer increased 76%—and mortality, 65%—across 195 countries and territories between 1990 and 2017. This year in the United States alone, 42,230 new cases of liver and intrahepatic bile duct cancers, and 30,230 associated deaths, are expected. Meanwhile, an estimated 11,980 new cases of gallbladder and other biliary cancers are also expected, with 4310 associated deaths.

Lisa E Davis, PharmD, FCCP, BCPS, BCOP, a professor at the University of Arizona and clinical pharmacist at the University of Arizona Cancer Center, discussed the state of targeted therapies for biliary tract cancers, as well as the role of oncology pharmacists in personalized treatment, during her Great Debates & Updates Oncology Pharmacy session.

Biliary tract cancers, she explained, are molecularly diverse tumors with distinct features. The current standard-of-care treatment for unresectable metastatic tumors is gemcitabine plus cisplatin. Compared with a median overall survival of 8.1 months with gemcitabine alone, gemcitabine plus cisplatin has a median overall survival of 11.7 months and a median progression-free survival of 8.0 months, according to the session.

Patients without molecularly targetable alterations could qualify for second-line and subsequent treatment with FOLFOX (folinic acid, fluorouracil, and oxaliplatin), Dr Davis explained. Median overall survival with FOLFOX is 6.2 months, and 12-month overall survival rate is 25.9%. Second-line treatment in the absence of molecularly targetable alterations could also include irinotecan-containing regimens or clinical trials.

Dr Davis recommended comprehensive genomic profiling of patients with advanced disease because as many as half could have actionable genomic alterations. Recent US Food and Drug Administration approvals for IDH1 inhibitors, FGFR2 inhibitors, and immune checkpoint inhibitors for biliary tract cancers have improved survival outcomes. NTRK fusions, MET amplification, PI3KCA hotspot mutations, ERBB2/EGFR overexpression, KRAS mutations, and DNA damage/repair pathway mutations are also potentially actionable.

“Pharmacists further promote better patient outcomes,” Dr Davis pointed out, “by facilitating access to therapies, assisting with treatment and dosing selections, preventing and managing treatment adverse effects, and supporting medication adherence.”

Specifically, pharmacists optimize treatment through comprehensive medication reviews, planning for and addressing drug-drug and drug-food interactions, and identifying potential preemptive dose adjustments. In addition to addressing criteria necessary for insurance company approval of medications needed for treatment, pharmacists support medication adherence by making themselves accessible to patients, responsive to their needs, and respectful of their preferences and values.